Every finding on record at August Healthcare at Leewood

Based on record review, interview, document review, and facility policy review, the facility failed to implement their abuse policy and ensure one resident (Resident (R) 94) of one reviewed for abuse was safe after R94 sustained an injury during activity of daily living (ADL) care by a Certified Nurse Aide (CNA), and the facility did not investigate to rule out that abuse occurred out of a total sample of 33 residents. The facility's failure to ensure residents were free from physical abuse caused or was likely to cause serious injury, harm, impairment, or death to a resident. Cross reference F609 and F610.An Immediate Jeopardy was identified on 04/30/26 and was determined to exist on 03/10/25, in the area of S483.12 Freedom from Abuse, Neglect, and Exploitation at a Scope and Severity (S/S) of a J. The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, and Regional Director of Operations were notified of the Immediate Jeopardy on 04/30/26 at 10:56 AM. Findings include: Review of R94's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included altered mental status. Review of R94's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/18/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderately impaired cognition. Further review revealed her preferred language was Korean. Review of R94's Care Plan, initiated on 12/17/25 and located under the Care Plan tab of the EMR, revealed . The resident will have no complications from discoloration. Further review revealed the care plan was not updated after R94 sustained injuries to her wrist on 03/20/25. During an interview on 04/29/26 at 10:30 AM, the Chief Executive Officer (CEO) stated it was not reported to the state survey agency (SSA), and they did not have an investigation for the incident that occurred on 03/20/25. The CEO stated they had a paper, and he would provide the paper. The CEO later provided the grievance form that he referred to as a paper. Review of facility provided Incident Report for Bruise, dated 03/20/25 at 9:45 PM and written by RN1 revealed, . Writer was informed by [CNA2] that resident developed discoloration of bilateral wrist during ADLS care when changing resident clothes [and the] resident was resisting care. Resident bumped bilateral wrist against the wheelchair during transfer. Discoloration and swelling were present. Further review revealed immediate action taken was assessed resident, resident asked to flex both hands for mobility, physician notified and ordered x-ray to rule out fracture. Per CNA2, the resident bumped wrists on wheelchair during the transfer and show [sic] bruising during the wheelchair transfer. CNA2 was removed from the assignment and immediately educated to stop providing care if a resident resists. CNA2 stated he would never intentionally harm a resident that she bumped arms [sic] rests during care. Three statements were provided to the survey team several hours later by CNA2, Registered Nurse (RN) 1 and CNA3. Review of the facility provided Employee Witness Statement, dated 03/20/25 and written by RN1 revealed, . He was informed that R94 was adamantly resisting care. During transfer, resident bumped her wrists against wheelchair causing discoloration. Ice bag was presented to mitigate pain, but resident still refused. Physician and resident representative were made aware of situation and ordered x-ray. Resident was interrogated but was unable to communicate coherent English. Review of the facility provided Employee Witness Statement, dated 03/20/25 and written by CNA2 revealed, . R94 hit arms down on wheelchair after transfer her back to wheelchair from toileting was going to transfer her back. Start hitting her arms up and down on wheelchair. I went to get CNA3 to attempt reapproach with another CNA. CNA2 return [sic] to her room. Return [sic] noticed discoloration to wrist area. Immediately notified charge nurse. Review of the facility provided Employee Witness Statement, dated 03/20/25 and written by CNA3 revealed, . I was asked to assist with R94. R94 was agitated in room. Her CNA got the nurse. The nurse assessed and called all the people he needed to notify. Review of R94's Nurse's Note, dated 03/20/25 at 11:35 PM written by Registered Nurse (RN) 1 and located under the Notes tab of the EMR, revealed, . Writer was informed by [CNA2] that resident developed discoloration of bilateral wrist after accident when changing clothes because patient was also resisting. Resident bilateral wrist was assessed. Discoloration and swelling were present. CNA was asked to get ice bag and apply them to affected areas for relief. During an interview 04/29/26 at 11:15 AM, CNA2 stated he was the assigned CNA to R94 during the 3-11 PM shift. At some point during that evening, he was getting R94 ready for bed. He first toileted R94 and then pushed her wheelchair to her bed and attempted to put her back to bed. He was standing in front of her, and he placed his arms under her armpit area and was trying to lift her, but he never actually lifted her out of the seat. CNA2 stated R94 resisted by lifting her arms above her waist, but she never swung them. He stated he asked her what happened and she just looked at him but did not scream. CNA2 stated he left R94's room and went and called a female CNA, CNA3 and they went back to the resident's room. They both put gloves on, and CNA3 attempted to lift R94, and then said Look. what is that? CNA2 stated it appeared to be a blistered area. He went and got RN1. RN1 came and asked what happened, and he told him he did not know. CNA2 said the nurse supervisor also came and asked him what happened. He told the supervisor that R94 was resisting, but he did not know how the injury happened. He said he applied ice to area, and he was still assigned to her for the rest of the shift. He thinks another CNA was assigned, but he was unsure who put R94 to bed. He was also unsure if he took her vitals. He stated he has been assigned to R94's unit and to her room, but he asked for another staff member to switch R94's room for another resident room. He said he was taken off the schedule for three days, and he was told the facility had to do their investigation. He stated to his knowledge the facility never figured out how R94 sustained the wrist injury. He confirmed the injury was not there prior to him attempting to put R94 to bed and transfer her out of the wheelchair. An interview was attempted on 04/29/26 at 11:51 AM with RN1 and was unsuccessful. A voice mail was left requesting a return call. During an interview on 04/29/26 at 12:01 PM, Family Member (FM) 1 stated R94 did not speak English. She stated she spoke with R94 about the incident that occurred on 03/20/25 and R94 told her she refused to be changed into the nightgown, and the staff grabbed her hand and tried to force her. She said it was a big black guy, but she did not know his name. FM1 stated she reported this allegation to a nurse and the prior Administrator. She stated a second incident happened on 06/29/25 in which R94 sustained wrist injuries after she refused to be changed into a nightgown by a big black male and that he held her hands down and tried to force her to allow him to change her. She stated she also reported it to adult protective services (APS) since the facility had not done an investigation into the allegation. During an interview on 04/29/26 at 2:43 PM, the Social Service Director (SSD) stated all reports of abuse were reported to the SSA within 24 hours. She stated during every investigation of abuse she would interview the resident and five other cognitive residents with a BIMS higher than 12 and complete a Trauma assessment. She stated she did not interview R94 about the abuse allegation/injury that occurred on 03/20/25, and she did not interview any other residents or complete a trauma assessment on R94. She stated the facility had a meeting and it was determined that abuse did not occur, but she was unsure how the facility came to that conclusion. She also stated she should have interviewed R94 and other residents about the 03/20/25 incident. During an interview on 04/29/26 at 3:35 PM, the Administrator stated she was the DON at the time of the incident on 03/20/25. She stated the facility should report all allegations of abuse/injury of unknown origin within two hours and immediately start an investigation. She stated they would interview all staff that worked with the resident in the last 72 hours or any staff that may have knowledge of the incident, the resident, and five other cognitive residents. She stated the incident that occurred on 03/20/25 was not reported because it was not an injury of unknown origin. She stated CNA2 self-reported that the injury occurred during care. She stated the facility determined that because CNA2 denied abuse and said it occurred during ADL care. She stated they only interviewed CNA2 and RN1. A review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 11/2021, revealed, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse. neglect or exploitation occur. Written procedures for investigations include Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.

Based on observations, record reviews, and interviews, the facility failed to accurately assess two residents (Resident (R) 8 and R140) reviewed for medications and wound assessment out of a total of 33 sampled residents. This failure had the potential of residents not having specific medications, monitoring needed and wound care. Findings include: 1.Review of R8's significant change Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/25/26 and located under the electronic medical record (EMR), revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderately impaired cognition. The MDS further revealed the following: mobility by wheelchair, touching assistance for transfers and bed mobility; incontinent of bowel and bladder; diagnosis of anemia, coronary artery disease, hypertension, hyperlipidemia, non-Alzheimer's dementia, anxiety, depression; has one unhealed stage three pressure related injury/ulcer that was not present on admission. Review of R8's Progress Notes, dated 12/22/25 written by the wound care provider and located under the Notes section of the EMR, revealed R8 had a left heel unstageable pressure injury that was present on admission. The wound care provider notes further indicated R8 had anemia, weakness, and hyperlipidemia, and all these conditions were chronic and stable. The plan was to continue the treatment per the wound care center of Aquacel (a soft, sterile, non-woven dressing designed for moderately to highly exuding chronic and acute wounds) to treat the left heel ulcer. During an interview and record review on 04/30/26 at 2:25 PM, the Minimum Data Set Coordinator (MDSC) 1 stated that R8 was in the facility when the wound changed. The MDSC stated that after completing a review of R8's chart the assessments should have reflected that R8's wound was on admission and not facility acquired. The MDSC stated that the assessments were incorrect. 2.Review of R140's quarterly MDS, with an ARD of 02/22/26 and located under the MDS tab of the EMR, revealed R140 had a BIMS score of 15 out of 15, indicating intact cognition. The MDS also revealed R140 received insulin injections, antidepressant, diuretic, and opioid medications during the observation period. Review of R140's Physician Orders, located under the Orders tab of the EMR revealed a physician's order for the anticoagulant Eliquis Oral Tablet 5 MG [milligrams] (Apixaban) Give one tablet by mouth two times a day for atrial fibrillation. During an interview and record review on 04/30/26 at 1:05 PM, the MDSC1 stated that the quarterly MDS on 02/22/26 did not reflect that R140 was receiving an anticoagulant. After a review of R140's physician's order the MDSC stated that R140 had been receiving an anticoagulant and the MDS assessment should have reflected that. During an interview on 04/30/26 at 5:35 PM, the Director of Nurses (DON) stated that the comprehensive assessments should reflect the resident's most current physician orders for medication and skin conditions. The DON stated that the comprehensive assessments help drive the care a resident receives.

Based on interview, record review, and policy review, the facility failed to report an allegation of potential abuse after Resident (R)94 sustained an injury during activity of daily living (ADL) care by a certified nurse aide (CNA) timely to the state survey agency for (SSA) for one of five residents (Resident (R) 94) reviewed for abuse out of 33 sampled residents. This had the potential to affect residents in the facility who were at risk for abuse. Cross reference F607 and F610.Findings Include: Review of R94's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included altered mental status. Review of facility provided Incident Report for Bruise, dated 03/20/25 at 9:45 PM and written by RN1, revealed, . Writer was informed by [CNA2] that resident developed discoloration of bilateral wrist during ADLS care when changing resident clothes [and the] resident was resisting care. Resident bumped bilateral wrist against the wheelchair during transfer. Discoloration and swelling were present. Further review revealed immediate action taken was assessed resident, resident asked to flex both hands for mobility, physician notified and ordered x-ray to rule out fracture. Review of R94's Nurse's Note, dated 03/20/25 at 11:35 PM, written by Registered Nurse (RN) 1 and located under the Notes tab of the EMR, revealed, . Writer was informed by [CNA2] that resident developed discoloration of bilateral wrist after accident when changing clothes because patient was also resisting. Resident bilateral wrist was assessed. Discoloration and swelling were present. CNA was asked to get ice bag and apply them to affected areas for relief. During an interview on 04/29/26 at 10:30 AM, the Chief Executive Officer (CEO) stated the incident that occurred on 03/20/25 was not reported to the SSA. During an interview on 04/29/26 at 3:35 PM, the Administrator stated she was the Director of Nursing (DON) at the time of the incident on 03/20/25. She stated the facility should report all allegations of abuse/injury of unknown origin within two hours. She confirmed this allegation was not reported to the SSA since they determined it was not an injury of unknown origin or abuse. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 11/2021, revealed, . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily inju

Based on interview, record review, and policy review, the facility failed to investigate an allegation of potential abuse after one resident (Resident (R) 94) sustained an injury during activity of daily living (ADL) care by a certified nurse aide (CNA) for one of five residents (Resident (R) 94) reviewed for abuse out of 33 sampled residents. This had the potential to affect residents in the facility who were at risk for abuse. Cross reference F607 and F609. Findings Include: Review of R94's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included altered mental status. Review of R94's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/18/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderately impaired cognition. Further review revealed her preferred language was Korean. Review of R94's Care Plan, initiated on 12/17/25 and located under the Care Plan tab of the EMR, revealed, . The resident will have no complications from discoloration. Further review revealed the care plan was not updated after R94 sustained injuries to her wrist on 03/20/25. Review of facility Incident Report for Bruise, dated 03/20/25 at 9:45 PM, and written by RN1 revealed, . Writer was informed by [CNA2] that resident developed discoloration of bilateral wrist during ADLS care when changing resident clothes [and the] resident was resisting care. Resident bumped bilateral wrist against the wheelchair during transfer. Discoloration and swelling were present. Further review revealed immediate action taken was assessed resident, resident asked to flex both hands for mobility, physician notified and ordered x-ray to rule out fracture. Review of R94's Nurse's Note, dated 03/20/25 at 11:35 PM, written by Registered Nurse (RN) 1, and located under the Notes tab of the EMR, revealed, . Writer was informed by CNA2 that resident developed discoloration of bilateral wrist after accident when changing clothes because patient was also resisting. Resident bilateral wrist was assessed. Discoloration and swelling were present. CNA was asked to get ice bag and apply them to affected areas for relief. During an interview on 04/29/26 at 10:30 AM, the Chief Executive Officer (CEO) stated they did not have an investigation for the incident that occurred on 03/20/25. The CEO stated they had a paper, and he would provide the paper. The CEO provided a copy of the grievance that he previously referred to as the paper. During an interview on 04/29/26 at 12:01 PM, Family Member (FM) 1 stated on 03/20/25 R94 told her she refused to be changed into the nightgown, and the staff grabbed her hand and tried to force her. FM1 stated she reported this allegation to a nurse and the prior Administrator. During an interview on 04/29/26 at 2:43 PM, the Social Service Director (SSD) stated during every investigation of abuse she would interview the resident and five other cognitive residents with a BIMS higher than 12 and complete a Trauma assessment. She stated she did not interview R94 about the abuse allegation/injury that occurred on 03/20/25, and she did not interview any other residents or complete a trauma assessment on R94. She stated the facility had a meeting and it was determined that abuse did not occur. She was unsure how the facility came to that conclusion. She also stated she should have interviewed R94 and other residents about the 03/20/25 incident. During an interview on 04/29/26 at 3:35 PM, the Administrator stated she was the Director of Nursing (DON) at the time of the incident on 03/20/25. After all allegations of abuse, they immediately start an investigation. She stated CNA2 self-reported that the injury occurred during care. She stated the facility determined abuse did not occur because CNA2 denied abuse and said it occurred during ADL care. She stated they only interviewed CNA2 and RN1 and nobody else. A review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 11/2021, revealed, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse. neglect or exploitation occur. Written procedures for investigations include Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing complete and thorough documentation of the investigation.

Based on record review, interviews, and policy review, the facility failed to ensure two of three residents (Resident (R) 48 and R124) and their resident representatives (RR) reviewed for emergent hospital transfer were provided with a written bed hold policy and transfer notice that contained the appeal process out of a total sample of 33 residents. This failure had the potential to affect the residents and their RR by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include:1. Review of R48's ''admission Record, located under the ''Profile'' tab of the electronic medical record (EMR), revealed R8 admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizophrenia, schizoaffective and adjustment disorder with mixed anxiety and depressed mood. Review of R48's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/16/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R48 was cognitively intact. Review of R48's Progress Note, dated 02/22/26 and 04/14/26 and located under the Progress Note tab of the EMR, revealed R48 had a change in condition and a new order was received to send R48 to the hospital for evaluation and treatment. Review of R48's Notice of Emergency Transfer, dated 02/22/26 and 04/14/26, provided by the facility, revealed that the document did not include the appeal process, and a copy was not provided to the resident or RR. 2. Review of R124's ''admission Record, located under the ''Profile'' tab of the EMR, revealed R124 admitted to the facility on [DATE] with diagnoses including muscle weakness. Review of R124's annual MDS, with an ARD of 03/31/26 and located under the MDS tab of the EMR, revealed a BIMS score of six out of 15, which indicated R124 was severely cognitively impaired. Review of R124's Progress Note, dated 01/11/26 and located under the Progress Note tab of the EMR, revealed R124 had a change in condition due to chest pain. Emergency Medical Services (EMS) was contacted, advised giving resident two doses of baby aspirin, and the resident was taken to the hospital. Review of R124's Notice of Emergency Transfer, dated 01/11/26, provided by the facility, revealed that the document did not include the appeal process and a copy was not provided to the resident or RR. During an interview on 04/30/26 at 4:40 PM, the Social Services Director (SSD) stated she did not provide a copy of the transfer notice to either the resident or their family. The family was made aware of the transfer, and the Ombudsman was also notified. She said they have been using the current form and were unaware there should be additional information that included the appeal information on it. During an interview on 04/30/26 at 4:52 PM, the Assistant Director of Nursing (ADON) said when a resident was transferred to the hospital, she completed the transfer form but gave that completed form to the SSD and they notified the physician and the family. During an interview on 04/30/26 at 5:37 PM, the Director of Nursing (DON) said she would expect facility staff to be in compliance with federal regulation. Review of the facility's policy titled, TRANSFER & DISCHARGE NOTIFICATIONSADMINISTRATION, dated 01/2026, revealed, . The facility will notify resident, or their representative as well as the Ombudsman of resident transfers and discharge. The facility will notify resident and the representative of transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. A record for the reasons for transfer or discharge in the resident's record will be included as well as a statement of the resident's appeal rights including name, address, telephone number of entities which receives such request.

Based on record reviews, interviews, and policy review, the facility failed to ensure that Preadmission Screening and Resident Review (PASARR) Level II assessment was submitted after a positive Level I assessment required it for one resident (Resident (R) 48) out of 33 sampled residents. This failure had the potential to affect all residents admitted to the facility with a known or suspected mental illness or intellectual disability from receiving services. Findings include:Review of R48's ''admission Record, located under the ''Profile'' tab of the electronic medical record (EMR), revealed R8 admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizophrenia, schizoaffective and adjustment disorder with mixed anxiety and depressed mood. Review of R48's Level I Screening, dated 01/15/26 and located under the Miscellaneous tab in the EMR, revealed a Level II screening was recommended. Further review revealed no documentation that a Level II referral was made. Review of R48's Nurse's Notes, dated January 2026 and located under the Notes tab of the EMR, revealed no documentation related to a Level II referral. During an interview on 04/28/26 at 2:18 PM, the Social Services Director (SSD) stated she did not have a fax confirmation that the PASARR Level II referral was sent and/or received. She does not keep them and throws them away. The SSD stated there should be a progress note when she faxed it in. She also stated that she had not followed up to check the status of the referral or if it was received. During an interview on 04/30/26 at 5:37 PM, the Director of Nursing (DON) stated a Level II should be completed timely and that it should not take three months. The DON stated a follow-up should have been completed before now, and she would have expected the staff to keep a fax confirmation to document when it was sent and that it was received. A review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR) [sic] & Specialized Services Review, revised 11/2025, revealed, . It is the policy of the facility to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) [sic] screening process (Level l) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMl/SMD) [severe mental illness/severe mental disorder], intellectual disability (lD), or related condition. Based upon the Level l screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. If a provisional admission to the facility is approved via the Level ll screen process, the facility will coordinate with the State PASRR [sic] representative related to the individual needs of the resident as indicated.

Based on observations, interviews, record reviews, and policy review, the facility failed to ensure a baseline care plan contained the information needed to provide care to one residents (Resident (R) 159) and failed to ensure a baseline care plan was created for one resident (Resident (R) 5) out of 33 sampled residents. This failure had the potential to cause the residents not to receive the appropriate care and services to meet medical, nursing, mental, and psychosocial needs. Findings include:1.Review of R159's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R159 admitted on [DATE] with a diagnosis of metabolic encephalopathy (brain dysfunction caused by a metabolic condition in the body). Observations of R159 on 04/27/26 at 11:36 AM; 04/27/26 at 2:30 PM; 04/28/26 at 1:26 PM; 04/28/26 at 4:01 PM; and 04/29/26 at 9:08 AM revealed the presence of an indwelling urinary catheter (Foley). Review of R159's Baseline Care Plan, dated 04/20/26 and located under the Assessments tab of the EMR did not reveal any interventions related to R159 utilizing a Foley catheter r/t [related to] a diagnosis of obstructive uropathy. The care plan did not reveal any interventions to care for R159's urinary catheter. The goal was that the Resident will be free from complications related to Foley. During an interview on 04/29/26 at 2:59 PM, the Director of Nursing (DON) revealed R159's indwelling catheter interventions were added to the baseline care plan on 04/29/26, nine days after R159 was admitted to the facility. The DON stated the catheter interventions got missed when R159 was admitted to the facility on [DATE]. The DON stated the supervisor on duty, at the time of admission, was responsible for initiating the baseline care plan and ensuring the information needed to care for R159 was included. 2.Review of R5's admission Record, located under the Profile tab of the EMR, revealed R5 was admitted on [DATE] with a diagnosis of end stage renal disease. Review of the Assessments, located under the Assessments tab in the EMR, did not reveal any documentation that R5's base line care plan was completed. During an interview and record review on 04/29/26 at 9:39 AM, Unit Manager (UM) 1 stated that the baseline care plan was not in the chart and was not completed. UM1 stated that the baseline care plan should have been completed within 48 hours of the resident admitting to the facility. During an interview on 04/29/26 at 9:59 AM, Minimum Data Set Coordinator (MDSC) 1 stated that the facility should have completed the baseline care plan for R5 within 48 hours of admission. MDSC1 stated that R5 was a new admission even though R5 was previously a resident at the facility. Review of the facility policy titled, Care Plan /Care Plan Meeting/Baseline Care Plan, with a revision date of 01/20/22, revealed the following: . The facility must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality of care. The facility will develop a baseline care plan within 48 hours and include the minimum healthcare information necessary to properly care for a patient including, but not limited to: Initial goals based on admission orders; physician orders; dietary orders; therapy services; social services.

Based on observations, interviews, record reviews, and policy review, the facility failed to ensure the comprehensive care plan contained the information necessary to provide care to one resident (Resident (R) 3) out of a total of 33 sampled residents. This failure had the potential to place the resident at risk of not receiving the appropriate care and services. Findings include:1.Review of R3's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R3 admitted on [DATE] with a principal diagnosis of hip fracture. Review of R3's admission Minimum Data Set (MDS), with an assessment reference date of 03/23/26 and located under the MDS tab of the EMR, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated R3 was cognitively intact. The MDS indicated R3 had an indwelling catheter. Review of R3's Care Plan, dated 03/18/26 revealed an Active problem with goals and interventions for an indwelling urinary catheter. Observations of R3 on 04/27/26 at 1:00 PM, 04/28/26 at 1:49 PM, and 9:15 AM on 04/29/26 revealed no evidence that R3 had an indwelling urinary catheter. During an interview with R3 on 04/29/26 at 4:35 PM, R3 confirmed she did not have an indwelling urinary catheter. Review of R3's Treatment Administration Record, for March 2026 and located under the Administration Records tab of the EMR, revealed R3's indwelling urinary catheter was discontinued on 03/29/26. During an interview and record review on 04/29/26 at 3:30 PM, the Director of Nursing (DON) confirmed R3's indwelling urinary catheter was discontinued on 03/29/26, and R3's Care Plan was not revised as required. The DON stated the indwelling urinary catheter problem should have been removed from R3's care plan when the indwelling urinary catheter was removed and interventions should have been implemented for post-catheter removal care. Review of the facility policy titled, Care Plan /Care Plan Meeting/Baseline Care Plan, revised on 01/20/22, revealed, . It is also the policy of the facility to ensure all residents have a person-centered individualized care plan as deemed appropriate. The care plan must be customized to each individual patient's preferences and needs. The care plan will focus on patient individual diagnosis, interventions, and goals. A comprehensive person-centered care plan will be developed for each patient and may describe issues such as the following: services that are to be furnished. Care plans must be developed to meet a resident's care needs, changes in condition, appropriate diagnosis as well as plan of care appropriate for meeting resident's care needs.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure interventions were in place to maintain an indwelling urinary catheter to prevent potential complications for one resident (Resident (R) 159) reviewed for urinary catheters out of a total sample of 33 residents. This failure had the potential to place R159 at risk for a urinary tract infection.Findings include:Review of R159's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R159 was admitted on [DATE] with a principal diagnosis of metabolic encephalopathy (brain dysfunction caused by a metabolic condition in the body). Review of R159's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/23/26 and located under the MDS tab in the EMR, revealed R159's MDS was in progress and had not been completed. During an observation of R159 on 04/27/26 at 11:36 AM, R159 had an indwelling urinary catheter. The catheter bag was uncovered and was visible from the door. R159's bed was in a low position, and the catheter urinary drainage bag and the catheter tubing, which connected the urinary drainage bag to the urinary catheter, were touching the floor. During an observation of R159 on 04/27/26 at 2:30 PM, R159's indwelling urinary catheter bag and tubing were touching the floor. During an observation of R159 on 04/28/26 at 1:26 PM, R159's indwelling urinary catheter tubing was touching the floor. During an observation of R159 on 04/28/26 at 4:01 PM, R159's indwelling urinary catheter tubing was touching the floor. Review of R159's Progress Notes, dated 04/20/26 and located under the Progress Notes tab of the EMR, revealed documentation that R159 had an indwelling urinary catheter upon admission to the facility. Review of R159's Order Summary Report, dated 04/29/26 and located under the Active Orders tab of the EMR, dated 04/29/26, did not reveal an active order for the indwelling urinary catheter. Review of R159's Treatment Administration Record, for April 2026 and located under the Administration Records tab of the EMR, revealed no documentation of the indwelling urinary catheter or care provision required to maintain the care and function of the catheter including monitoring, cleaning, or changing the catheter. During an observation on 04/29/26 at 9:27 AM, Licensed Practical Nurse (LPN) 7 performed indwelling urinary catheter care for R159. LPN7 wiped the catheter with a pre-moistened wipe from just above the connection with the catheter and urinary drainage bag to the meatus [the external opening of the urethra, or urinary tube, where urine exits the body] three times wiping from distal to proximal towards the meatus, where the catheter was inserted. LPN7 then cleaned the labia from back to front on each side toward the meatus and wiped the catheter again from distal to proximal. During an interview on 04/29/26 at 2:07 PM, the Infection Preventionist (IP) indicated catheter care should be done by wiping the catheter away from the meatus and the perineum should be cleaned from front to back. The IP confirmed catheter bags and tubing should not touch the floor. During an interview on 04/29/26 at 2:59 PM, the Director of Nursing (DON) confirmed R159's indwelling urinary catheter orders got missed when R159 was admitted to the facility on [DATE] and should have been documented on R159's Order Summary Report and Treatment Administration Record so the facility staff were aware that urinary catheter care needed to be provided. Review of the facility policy titled, Urinary Catheter Protocol, revised on 11/01/22, revealed, . Purpose: To maintain catheter function, prevention of infection, ensure resident comfort, and promote safety. Catheter Care: Clean catheter area with soap and warm water; clean from front to back; clean 4-6 inches of catheter tubing extending from meatus; Drainage Bag: Drainage bag.should not touch floor.

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of three residents (Resident (R) 164) reviewed for side rails out of 33 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include:Review of R164's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy. Review of R164's entry Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/20/26 and located under the MDS tab in the EMR, revealed a Brief Interview for Mental Status (BIMS) had not been completed due to the resident being newly admitted . Review of R164's Care Plan, located under the Care Plan tab of the EMR, initiated on 04/20/26, revealed R164 was not care planned for bed rails. Review of R164's Physician Orders, dated 04/20/26 and located under the Orders tab of the EMR, did not reveal a current order for bed rail use. During an observation on 04/28/26 at 11:12 AM, R164 was resting in bed, with the head of bed (HOB) upright, with bed rails up on both sides. Review of R164's Admission/re-admission Screening-Side Rail, assessment dated [DATE] and located under Assessments tab in the EMR, revealed the rails were not indicated at this time. Further review revealed no documentation that alternates were explored prior to bed rail/side rail use or documentation related to risks versus benefits or informed consent. During an interview and record review on 04/30/26 at 1:34 PM, Licensed Practical Nurse (LPN) 6 stated on admission there was a questionnaire that staff completed, and residents were asked if they wanted bed rails, and there was an assessment in the EMR. LPN6 viewed the resident's assessment and said it was checked that the resident consented but stated a resident should not have bed rails if the assessment stated bed rails were not indicated. During an interview on 04/30/26 at 1:44 PM, Registered Nurse (RN) 2, who completed R164's bedrail assessment stated residents did not use bed rails unless it was for resident safety. RN2 stated R164 should not have bedrails if the assessment she completed indicated they were not going to be used. During an interview on 04/30/26 at 5:37 PM, the Director of Nursing (DON) stated residents should not have bed rails on their bed unless the clinical team has assessed them to have them. She said R164 should not have the bed rails on her bed. A review of the facility's policy titled, Bed Safety/Bedrails, revised 02/02/26, revealed, . The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Before using side rails for any reason, the staff shall inform the resident and family about the benefit and potential hazards associated with side rails.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors occurred out of 28 opportunities for error due to residents not receiving their medication on time for two residents (Resident (R) 85 and R35) out of six residents observed for medication administration. The facility medication error rate was 7.14%. This failure had the potential for residents not to receive the full beneficial effects of the prescribed medications.Findings include:1. Observations during medication administration on 04/29/26 at 9:21 AM, revealed Licensed Practical Nurse (LPN) 3 failed to administer R35's Vitamin D3 (a vitamin for immune system support) 125 microgram (mcg) one tablet during the time allotted 7:00 AM-9:00 AM.Review of R35's Physician Orders, dated April 2026 and located under the Orders tab of the electronic medical record (EMR), indicated there was a physician's order for Vitamin D3 125 mcg every Wednesday at 8:00 AM. 2. Observations during medication administration on 04/29/26 at 10:23 AM, revealed that LPN4 failed to administer R85's Tylenol 500 milligram [mg] (an over-the-counter pain-reliever).Review of R85's Physician Orders, dated April 2026 and located under the Orders tab in the EMR, indicated there was a physician's order for Tylenol 500 mg two a day for pain at 9:00AM- and 17:00 [5:00 PM]. During an interview on 04/30/26 at 5:00 PM, The Director of Nurses (DON) stated medications should always be given during that two-hour window, if not the physician should be notified and a new order written regarding that late medication. Review of the facility policy titled, Medication Pass/Administration, revised on 12/02/25, revealed . It is the policy of the facility to ensure safe administration of medications to our residents by licensed nurses according to acceptable professional standards. Under Medication Pass Procedure: .Medication must be administered between 2-hour window (1 hour before, on time and 1 hour after.

Based on observation, interview, record review, and policy review, the facility failed to provide food storage in a safe and consistent manner. This had the potential to affect three residents who received thickened liquids from the kitchen.Findings include:During an observation and initial kitchen walk through with the Dietary Manager (DM) on 04/27/26 beginning at 10:30 AM, the following was observed in the dry storage: - One large bag of Japanese breadcrumbs opened without displaying an open date or a use by date. - One opened case containing four 42-ounce cartons of honey thickened liquid with a use by date of 07/01/25.- One opened case with three 42-ounce cartons of honey thick liquid with a use by date of 02/07/26. - Two unopened cases of nectar thick tea with use by date of 12/20/25. - Five 42-ounce cartons of nectar thick water with a use by date of 07/20/25.- Nine cartons of thickened cranberry juice with a use by date of 07/20/25. During an interview on 04/27/26 at 11:05 AM, the Dietary Manager (DM) stated items that were beyond the manufacture's use by date should not be on the shelf. Review of the undated facility policy titled, Food Receiving and Storage, revealed, . that all expired food or items must be discarded by the use date.

Based on record review and interview the facility failed to provide pneumococcal immunization as require or appropriate for one resident (Resident #1), and failed to provide documentation as to why the COVID-19 vaccination was not provided for one resident (Resident #2) in a sample of five residents. The findings included: On 08/23/22 at approximately 11 a.m., an electronic health record (EHR) review was conducted. Resident #1 was noted to not have refused the COVID-19 vaccination. However, there was no documentation as to the basis of not providing the vaccination. On 08/23/22 at approximately 11:15 a.m., an electronic health record (EHR) review was conducted. Resident #2 was noted to not have been administered a pneumococcal vaccination. On 08/23/22 at approximately 12:00 p.m., conducted a review August Healthcare Policy & Procedure, title: Pneumococcal Vaccination. The policy states that it is the policy of the facility that all residents be provided the opportunity and encouraged to receive pneumococcal vaccinations. On 08/24/22 at approximately 10 a.m. conducted an interview with the Infection Preventionist. The infection preventionist acknowledged that: 1). Resident #1's record did not contain documentation detailing why the COVID-19 immunization was not administered. 2). Resident #2's had not been offered nor receive a pneumococcal immunization. During the end of day meeting the facility Administrator and DON was made aware of the above findings and no further information was provided.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain one of three of the facility dumpsters in a sanitary manner. A trash bag approximately half full of trash was hanging on the outside of the dumpster and approximately twelve pairs of used plastic gloves and numerous pieces of debris were found lying on the ground around and behind the facility's dumpster. The findings include: On 03/15/22 at approximately 11:50 a.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) # 1, dietary manager, OSM # 2, director of maintenance, OSM # 3, director of housekeeping and OSM # 4, housekeeper. The observation revealed that the facility had two trash dumpsters and one cardboard recycling dumpster and one dumpster for trash, next to each other located behind the facility. Observations of the area between and behind the two dumpsters revealed a broken mop handle between the two dumpsters, approximately 12 pairs of used plastic gloves, and numerous pieces of trash - behind the two dumpsters, mixed in and lying on top of decaying leaves and pine needles. Further observation revealed a trash bag, approximately half full of trash, hanging on the outside of the dumpster. When asked who was responsible for ensuring the dumpster area was kept clean, OSM # 2 stated, We call the company to come and empty the dumpsters and housekeeping is responsible for cleaning up around the dumpsters. The dumpsters were emptied this morning. When asked how often the dumpster area was cleaned and checked OSM # 3 stated, Every morning. When asked about the trash observed on the ground around the dumpsters OSM # 3 stated, [Name of OSM # 4] is responsible for cleaning up around the dumpster. OSM # 4 was asked how often they clean up around the dumpster, OSM # 4 stated, Every morning. When asked if they had come out to clean up around the dumpsters after they were emptied earlier that morning, OSM # 4 stated, No I was going to come out this afternoon. When asked why it was important to keep the dumpster areas clean and free from debris, OSM # 3 stated, For sanitary purposes, prevent rats and mice from coming around. The facility's policy External Environmental Cleaning documented in part, 5. Areas around the buildings (i.e., sidewalks, patios, gardens, dumpster area, etc.) shall be always maintained in a safe and orderly manner. On 03/16/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and implement the comprehensive care plan for six of 47 residents in the survey sample, Residents #56, #28, #39 , #11, #71 and #2 . The findings include: 1. The facility staff failed to develop a comprehensive care plan to address Resident # 56's pain. Resident # 56 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J coded Resident # 56 as not having any pain in the past 5 (five) days. The physician's order sheet for Resident # 35 dated February 2022 documented in part: [MEDICATION(S)]-Acetaminophen (1) 10-325 MG (milligram) Tablet. Give one tablet by mouth twice daily as needed. Order Date: 04/23/2021. Resident #56's eMAR (electronic medication administration record) for March 2022 documented the administration of the [MEDICATION(S)]-Acetaminophen as documented above on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 03/01/2022 at 4:31 p.m., 03/02/2022 at 7:23 a.m., 03/03/2022 at 4:54 p.m., 03/04/2022 at 5:42 p.m., 03/07/2022 at 7:00 p.m., 03/09/2022 at 9:19 p.m., 03/13/2022 at 5:22 a.m. and on 03/15/2022 at 4:44 p.m. The comprehensive care plan for Resident # 56 dated 04/29/2021 failed to evidence information related to pain. On 03/17/22 at approximately 10:52 a.m., an interview was conducted with Resident # 56. When asked if they receive pain medication as needed Resident # 56 stated, Sometimes. When asked if the staff try to alleviate their pain before giving them pain medication Resident # 56 stated Sometimes. On 03/16/2022 at approximately 2:20 p.m. an interview was conducted with LPN [licensed practical nurse] # 3, MDS coordinator regarding the comprehensive care plan for Resident # 56. When asked to describe the purpose for a care plan LPN # 3 stated, To coordinate resident care and work out a plan of care for the resident. When asked how the comprehensive care plan is developed for a resident LPN # 3 stated, Go with the triggers from the comprehensive assessment and develop the care plan and we follow the RAI (resident assessment instrument) manual When informed of a missing care plan to address Resident # 56's pain, LPN # 3 stated, I'll check the care plan. At approximately 4:18 p.m., LPN # 3 stated, There's no care plan for [Name of Resident # 56's] pain and there should be. The facility's policy Care Plans, Comprehensive Person-Centered documented in part, 8. The comprehensive, person-centered care plan will: a. Include e measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The Resident Assessment Instrument (RAI) User's Manual. 4.7 The RAI and Care Planning documented in part, As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Refer to 42 CFR 483.20(d), which notes that a nursing home must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. On 03/16/2022 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit. References: (1) Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4. 2. The facility staff failed to implement Resident # 28's comprehensive care plan for the use of a fall mat. Resident # 28 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 12/30/2021, the resident scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On the following dates a times, Resident #28 was observed to bed, with no fall mat in place on the floor next to the bed: 03/15/22 at 12:40 p.m., 03/15/22 at 4:55 p.m., 03/16/22 at 8:05 a.m., and 03/16/22 at 12:00 p.m. At each observation, a fall mat was leaning against the wall at the foot of Resident #28's bed. The facility's fall investigation for Resident # 28 dated 11/27/2021 documented in part, Resident c/o (complaint of) chest pain bout 6:30 am. (a.m.). Chest pain protocol initiated - O2, (oxygen), 3 (three) doses of Nitro, Aspirin given in am (a.m.). Unresolved. Resident rolled out of bed inspite [sic] of being placed at the middle and low bed position. No injuries sustained. The comprehensive care plan for Resident # 28 with a revision date of 11/27/2021 documented in part, Focus: The resident has had an actual fall related to sudden chest pains, dizziness, and shortness of breath. Date Initiated: 11/27/2021. Revision on: 11/29/2021 .Safety fall protocol in place- .fall mats in place . Date Initiated: 11/27/2021. Revision on: 11/29/2021. On 03/16/2022 at approximately 12:20 p.m. an interview was conducted with LPN [licensed practical nurse] # 2. When asked if Resident # 28 needed a fall mat next to their bed LPN # 2 stated, No because he's not a fall risk. After informed of the above observations and reviewing the comprehensive care plan dated 11/27/2021 LPN # 2 was asked again if Resident # 28 needed a fall mat. LPN # 2 stated, Yes, it should be down next to his bed. When asked to describe the purpose of a care plan LPN # 2 stated, What kind of care to provide to the resident. When asked if the care plan was being followed if the fall mat was not on the floor next to the resident's bed LPN # 2 stated, No. On 03/16/2022 at approximately 12:25 p.m. an interview was conducted with RN [registered nurse] # 2, unit manager. When asked if a fall mat should be on the floor next to Resident # 28's bed when they are in bed RN # 2 stated, Yes. When informed of the above observations RN # 2 stated, It should have been in place. When asked to describe the purpose of a care plan RN # 2 stated, Tells how to take care of the resident. When asked if the care plan was being followed if the fall mat was not on the floor next to the resident's bed RN # 2 stated, Not at this time. On 03/16/2022 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to implement the comprehensive care plan to measure and observe the pressure injury for Resident #39. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/6/2022, Resident #39 was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. In Section M, the resident was coded as having no unhealed pressure injuries. The comprehensive care plan dated 12/19/2021, and reviewed on 3/16/2022, documented in part, Focus: The resident has non rupture blister on right inner heel .Weekly treatment documentation to include measurement of each are of skin breakdown's width, length, depth, type of tissue and exudate and any other notable change or observations. The nurse's note dated 12/19/2021 at 3:39 p.m. documented in part, Resident has non ruptured blister noted to her rt (right) inner heel. Measured 4x4. Elevated heel on pillow. Apply skin prep bid (twice a day) and monitor any change. In house wound consult .No sign and symptoms of verbal or non verbal pain or discomfort noted. The Weekly Non-Pressure Wound Observation Tool dated 12/19/2021 at 12:01 p.m. documented in part, Type of Wound - Other; Location - blister on the right heel, Describe the wound - non punctured blister, no infectious process. Date wound noted: 12/19/2021 .Comments: Blister not punctured. Drainage: none. Odor: none. Wound measurements: Length: 2 cm (centimeters), Width: 3 cm, Depth: blank. Describe wound edges and shape: Well defined. Treatment: placed skin prep applied, heels were floated. Evaluation: First observation. Comments: Wound care to treat and evaluate for healing. The Weekly Skin Review dated 12/27/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 12/30/2021 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/3/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/6/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/10/2022 documented in part, Skin Condition: Open area - pre-existing - no site documented. The Weekly Skin Review dated 1/17/2022 documented in part, Skin Condition: Open area - pre-existing - RT (right) heel remains. The Weekly Skin Review dated 1/20/2022 documented in part, Skin Condition: Open area - pre-existing - Tx (treatment) to right heel remains. The Weekly Skin Review dated 1/24/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel. The Weekly Skin Review dated 1/27/2022 documented in part, Skin Condition: Open area - pre-existing - tx continues to right heel. The Weekly Skin Review dated 1/31/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 2/7/2022 documented in part, Skin Condition: Open area - pre-existing- Tx in progress to right heel with skin prep. The Weekly Skin Review dated 2/14/2022 documented in part, Skin Condition: Open area - Pre-existing- no site documented. The Weekly Skin Review dated 2/21/2022 documented in part, Skin Condition: Open area - pre-existing - Tx continues to right heel with skin prep. The Weekly Skin Review dated 2/28/2022 documented in part, Skin Condition: Open area - pre-existing - right heel - tx in progress. The Weekly Skin Review dated 3/7/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. The Weekly Skin Review dated 3/14/2022 documented in part, Skin Condition: Open area - pre-existing - Tx in progress to right heel. On all of the above documents, there were no measurements of the heel wound. Review of the nurse's note from 1/1/2022 through 3/2/2022 revealed no documentation of the right heel wound measurements. The NP wound specialist note, dated 3/2/2022, documented in part, Opened DTI (deep tissue injury), now devolved into an unstageable pressure wound. Measurements: length - 0.95 cm (centimeters), width - 1.13 cm, depth - 0.2 cm. An interview was conducted with LPN #3, the MDS nurse, on 3/16/2022 at 2:22 p.m. When asked the purpose of the care plan, LPN #3 stated it was the plan of how to care for the resident. When asked if it should be followed, LPN #3 stated, Yes. An interview was conducted with LPN #1 on 3/16/2022 at 2:25 p.m. When asked if she was aware of the wound on Resident #39's right inner heel, LPN #1 stated, In late January. When asked when it was determined to be a deep tissue injury and no longer a blister, LPN #1 stated, In late January. When asked if there were any measurements of this wound prior to 3/2/2022, LPN #1 stated, No. When asked why there were no measurements prior to 3/2/2022, LPN #1 stated, I don't know. LPN #1 further stated the normal process when the nurse tells her about an area is for both of them to go in to look at the area of concern. The unit manager also goes with them to assess the area and put a treatment in place. ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the director of nursing, ASM #4, the administrator from a sister facility, and RN #3, the staff development nurse, were made aware of the above concerns on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit. 4. The facility staff failed to develop a comprehensive care plan for the use of compression stockings for Resident #11. Resident #11 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set), an admission assessment with an ARD (Assessment Reference Date) of 12/9/21, the resident scored a 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A review of the physician's orders revealed the following order dated 12/2/21: Apply TED Hose/Compression Stockings (1) in the AM (morning) as resident tolerates. On 3/16/22 at 1:00 PM the resident was observed in bed without the stockings on. On 3/16/22 at 1:02 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). She stated that the resident had them on this morning when she was up, but that she wants them off when she is in bed. A review of the comprehensive care plan revealed no information regarding the use of compression stockings. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3, the MDS nurse. She stated that the purpose of the care plan was, To coordinate the resident care, work out a plan of care for that resident. When asked if compression stockings should have been included in the care plan if there was an order at the time of admission for them, she stated it should have been. When asked who is responsible to develop the comprehensive care plan, she stated, MDS is responsible for the development of the care plan. A review of the facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Compression stockings - You wear compression stockings to improve blood flow in the veins of your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. If you have varicose veins, spider veins, or have just had surgery, your health care provider may prescribe compression stockings. Wearing stockings helps with: Aching and heavy feeling in legs; Swelling in legs; Preventing blood clots, primarily after surgery or injury when you are less active; Preventing complications of blood clots in the legs, such as post-phlebitic syndrome (pain and swelling in the leg) . Information obtained from https://medlineplus.gov/ency/patientinstructions/ 7.htm 5. The facility staff failed to develop a care plan for use of a hand splint for Resident #71. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. Section G documented Resident #71 as being totally dependent on two or more staff for bed mobility, transfers, dressing and personal hygiene. Section O documented Resident #71 using a splint or brace. On 3/15/2022 at approximately 12:45 p.m., an observation of Resident #71 was made in their room. Resident #71 was observed in bed wearing a hand splint on the right hand. The ADL (activities of daily living) documentation survey report for 3/1/2022-3/31/2022 documented in part, Restorative: Splint- Apply Bilateral upper hand resting splint x 2 hrs a day on at 11am, off at 1pm or as tolerated. The comprehensive care plan for Resident #71 failed to evidence use of a hand splint. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plans were the responsibility of the unit manager, the MDS staff, and the nurses. LPN #5 stated that the care plan was to show a progression of care and to guide them in patient care. LPN #5 stated that splints should be documented on the care plan. On 3/16/2022 at 2:19 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the purpose of the care plan was to coordinate resident care and work out a plan of care for the resident. LPN #3 stated that they go over the triggers after completing the comprehensive assessment and completed the care plan. LPN #3 stated that the nurses completed the care plans for changes in condition or specific incidents. LPN #3 stated that they would review Resident #71's record and see if the splint was addressed on the care plan. On 3/16/2022 at 4:18 p.m., LPN #3 stated that she had reviewed the record and there was an old care plan from the previous facility owners but it had not been carried over with the new company. LPN #3 stated that the splint should be on the current care plan. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 6. For Resident #2, the facility staff failed to develop a care plan for the use of oxygen (A), and for skin integrity concerns (B). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. Section M documented Resident #2 having 1 Stage 3 pressure ulcer. Section O failed to evidence documentation of oxygen use. A. Resident #2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/2022 at 12:19 p.m., an observation was made of Resident #2 in their room. Resident #2 was observed receiving oxygen via a nasal cannula attached to an oxygen concentrator. At this time an interview was conducted with Resident #2 who stated that they wore the oxygen all the time and had used oxygen for a long time. The physician orders for Resident #2 documented in part, Oxygen at 1 liter per min (minute) via nasal cannula to maintain sats (saturations) above 92%. Order Date: 8/16/2021. The comprehensive care plan for Resident #2 failed to evidence use of oxygen. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plans were the responsibility of the unit manager, the MDS staff, and the nurses. LPN #5 stated that the care plan was to show a progression of care and to guide them in patient care. LPN #5 stated that the care plan was to be updated when there was any new treatment, infection or change in condition. LPN #5 stated that oxygen should be documented on the care plan. On 3/16/2022 at 2:19 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the purpose of the care plan was to coordinate resident care and work out a plan of care for the resident. LPN #3 stated that they go over the triggers after completing the comprehensive assessment and completed the care plan. LPN #3 stated that the nurses completed the care plans for changes in condition or specific incidents. LPN #3 stated that they would review Resident #2's record and see if the oxygen was addressed on the care plan. On 3/16/2022 at 4:18 p.m., LPN #3 stated that she had reviewed the record and oxygen was not on the care plan. LPN #3 stated that there should be a care plan for oxygen for Resident #2. On 3/16/2022 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. B. The wound evaluation note dated 3/2/2022 documented in part, Left lateral leg, Length: 1.36cm (centimeter), Width: 0.80cm, Depth: 0.00cm .Date Wound Acquired: 3/2/22; Nonblanchable [CONDITION(S)] (redness) surrounding a subcentimeter site of desquamation. [MEDICATION(S)] paste to wound and peri-wound Q (every) shift. Wound status: New; Acquired in house? Yes; Etiology: Pressure Ulcer- Stage 2 . The wound evaluation note dated 3/2/2022 documented in part, Sacrum, Length: 2.49cm, Width: 2.97cm, Depth 0.00cm .Date Wound Acquired: 3/2/22; Recurrent stage 3 pressure injury. Barrier cream to sacrum q shift. Wound status: New; Acquired in house? Yes; Etiology: Pressure Ulcer- Stage 3 . The comprehensive care plan for Resident #2 failed to evidence a care plan regarding pressure injuries or skin integrity. On 3/16/2022 at 12:15 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plans were the responsibility of the unit manager, the MDS staff, and the nurses. LPN #5 stated that the care plan was to show a progression of care and to guide them in patient care. LPN #5 stated that almost all residents had the potential for skin integrity issues and were care planned for them. LPN #5 stated that Resident #5 should have a care plan for pressure injuries because there was a history of them. On 3/16/2022 at 2:19 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the purpose of the care plan was to coordinate resident care and work out a plan of care for the resident. LPN #3 stated that they go over the triggers after completing the comprehensive assessment and completed the care plan. LPN #3 stated that the nurses completed the care plans for skin conditions. LPN #3 stated that they would review Resident #2's record and see if pressure injuries/skin integrity was addressed on the care plan. On 3/16/2022 at 4:18 p.m., LPN #3 stated that she had reviewed the record and Resident #2 did not have a care plan for skin integrity and should have one. On 3/16/2022 at 5:20 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and/or revise the comprehensive care plan for 6 of 47 residents in the survey sample, Residents #33, #34, #86, #11, #101, and #81. The findings include: 1. The facility staff failed to review and revise Resident #33's comprehensive care plan for the use of grab bar bed rails. Resident #33 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/30/21, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A physical therapy progress note dated 9/23/21 documented Resident #33 used bed rails for bed mobility. A review of Resident #33's comprehensive care plan dated 10/5/21 failed to reveal documentation regarding grab bar bed rails. A review of Resident #33's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/15/22 at 1:07 p.m., Resident #33 was observed in bed with bilateral grab bar bed rails in the upright position. On 3/16/22 at 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the minimum data set coordinator). LPN #3 stated the purpose of the care plan is to coordinate resident care and work out a plan of care for that resident. LPN #3 stated she believed residents' care plans should be reviewed and revised to include the use of grab bars because grab bars can cause injury so staff has to review the care plan to see if residents still need grab bars. On 3/16/22 at approximately 5:50 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Plan/Care Plan Meeting/Baseline Care Plan failed to document specific information regarding reviewing and revising the comprehensive care plan. No further information was presented prior to exit. 2. The facility staff failed to review and revise Resident #34's comprehensive care plan for the use of grab bar bed rails. Resident #34 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/28/21, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. An occupational therapy discharge summary dated 1/12/21 documented a recommendation for grab bars. A review of Resident #34's comprehensive care plan dated 10/15/2 failed to revealed documentation regarding grab bar bed rails. A review of Resident #34's March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/15/22 at 1:36 p.m., Resident #34 was observed in bed with bilateral grab bar bed rails in the upright position. On 3/16/22 at 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the minimum data set coordinator). LPN #3 stated the purpose of the care plan is to coordinate resident care and work out a plan of care for that resident. LPN #3 stated she believed residents' care plans should be reviewed and revised to include the use of grab bars because grab bars can cause injury so staff has to review the care plan to see if residents still need grab bars. On 3/16/22 at approximately 5:50 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to revise the comprehensive care plan for the use of compression stockings and a hand splint for Resident #86. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 2/9/22, Resident #86 was scored as having short term and long term memory problems and being moderately impaired in cognitive skills for daily decision making. The resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22 at 12:06 PM, Resident #86 was observed up in her recliner, dressed. She did not have compression stockings or a hand splint on. 03/16/22 12:08 PM an interview was conducted with CNA #3 (Certified Nursing Assistant) and LPN #10 (Licensed Practical Nurse). They stated that the resident frequently refuses the stockings or wants them removed after they have been on a while. They stated that she does not like to wear them. Regarding the hand splint, they stated that they will put it on in the morning and then the resident will remove it at some point and won't wear it. A review of the comprehensive care plan failed to reveal any evidence of the compression stockings or hand splint being care planned for use. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3, the MDS nurse. She stated that the purpose of the care plan was To coordinate the resident care, work out a plan of care for that resident. When asked if the comprehensive care plan should have been revised to include these items, she stated it should have been. When asked who is responsible for reviewing and revising the comprehensive care plan, she stated, The nurse caring for the resident. On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. References: (1) Compression stockings - You wear compression stockings to improve blood flow in the veins of your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. If you have varicose veins, spider veins, or have just had surgery, your health care provider may prescribe compression stockings. Wearing stockings helps with: Aching and heavy feeling in legs; Swelling in legs; Preventing blood clots, primarily after surgery or injury when you are less active; Preventing complications of blood clots in the legs, such as post-phlebitic syndrome (pain and swelling in the leg) . Information obtained from https://medlineplus.gov/ency/patientinstructions/ 7.htm (2) Splint - A splint is a rigid or flexible device that maintains in position a displaced or movable part, also used to keep in place and protect an injured part to support healing and to prevent further damage Purpose of Splinting: Immobilization; Support to promote healing; Positioning or supporting during function; Pain relief; Substitute for weak muscles; Correction and prevention of contracture & deformity; Restoring or maintaining of range of motion; [CONDITION(S)] control . Information obtained from https://www.physio-pedia.com/Splint 4. The facility staff failed to revise the comprehensive care plan for nutritional needs related to weight loss for Resident #11. On the most recent MDS (Minimum Data Set), an admission assessment with an ARD (Assessment Reference Date) of 12/9/21, Resident #11 scored a 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. The resident was coded as requiring limited assistance for eating. A review of the clinical record revealed the following weights: 3/3/2022 - 125.0 pounds, 2/3/2022 - 125.9 pounds, 1/4/2022 - 126.4 pounds, 12/30/2021 - 127.4 pounds, 12/16/2021 - 129.0 pounds, and 12/2/2021 - 129.4 pounds. This reflected a 4.4 pound weight loss in the approximately 90 day period since the resident was admitted and the weight that was obtained on 3/3/22. Further review of the clinical record revealed a dietary note dated 12/30/21 that documented, current weight: 127.4 lbs (pounds), down from weight on admission: 129.4 lbs. BMI (body mass index): 19.4, below healthy range for age. Diet: regular/regular/no added salt. Intake for the past 7 days 52% average Current diet is appropriate Supplement in place fortified foods with meals to help meet needs. Intake of meals not always meeting needs at this time. Met with resident in room, Resident stated she has enough to eat. Asked if she would like ice cream with meals, Resident stated yes, she would like that Plan: add ice cream to lunch and dinner meals, continue to monitor on weekly wts x 4 weeks. A dietary quarterly review dated 3/15/22 documented, Recent changes in Weight: Yes. Percent weight change in 30 days: 0.0. Percent weight change in 90 days: -3.40. Percent weight change in 180 days: n/a (not applicable) A review of the comprehensive care plan revealed nutritional related care plans for diabetes, [CONDITION(S)], and vitamin B12 deficiency. However, risk of weight loss and related nutritional needs had not been care planned after the resident exhibited a trend of mild weight loss in the first 90 days after admission. On 3/16/22 at 2:20 PM an interview was conducted with LPN #3, the MDS nurse. She stated that the purpose of the care plan was To coordinate the resident care, work out a plan of care for that resident. When asked if the care play should be revised if there was a weight loss since admission, she stated that it should be. When asked who is responsible for reviewing and revising the comprehensive care plan for nutritional and weight needs, she stated the dietician should be doing that. On 3/17/22 at 8:15 AM an interview was conducted with OSM #10 (Other Staff Member) the dietitian. When asked about a care plan related to the resident's weight loss and related nutritional needs, she stated that care plans are a joint effort and nutrition concerns are something the dietician would be involved in. She stated that the resident consumed 50% to 75% most days and 100% on some days. She stated that it would not have triggered a care plan for actual or significant weight loss as it was not a significant weight loss. When asked if, based on the 12/30/21 note wherein the resident was evidencing a trend of mild post admission weight loss, the weight loss should have been added to the care plan, she agreed. On 3/16/22 at 5:19 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Assistant Director of Nursing, ASM #4 Administrator of sister facility, and RN #3 (Registered Nurse) Staff Development, were made aware of the findings. No further information was provided by the end of the survey. 5. The facility failed to revise the comprehensive care plan to include bed rails for Resident #101. Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility. A review of Resident #101's care plan dated 2/17/22 revealed no information related to grab bars. A review of the physical therapy treatment encounter notes dated 3/2/22 which revealed the following, Bed mobility cue to use bed rail to roll to side. The resident was observed in bed with one quarter grab bars on 3/15/22 at 12:53 PM. When asked if he used the grab bars, Resident #101 stated, Yes, I use them on my one side to move a little. An interview was conducted on 3/16/22 at 2:20 PM with LPN (licensed practical nurse) #3, the MDS coordinator. When asked the purpose of the care plan, LPN #3 stated, The purpose is to coordinate the resident care, work out a plan of care for that resident. MDS is responsible for the development of the care plan. When asked if grab bars should be included on the care plan, LPN #3 stated, Yes I believe so. The care plan should be reviewed and revised to include them. When asked why the care plan should include the grab bars, LPN #3 stated, The care plan should include the grab bars because the resident could have injury with the grab bar and we need to review the care plan and check if they still need them. An interview was conducted on 3/16/22 at 3:03 PM with LPN #4. When asked if grab bars should be on the care plan, LPN #4 stated, Yes, they should be on the care plan. Usually under falls. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 6. A. The facility failed to revise the comprehensive care plan to include bed rails for Resident #81. Resident #81's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 2/16/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility. A review of Resident #81's care plan dated 2/9/22 revealed no information related to grab bars. A review of the physical therapy treatment encounter notes dated 2/11/22 which revealed the following, Using bedrails to roll side to side. The resident was observed in bed with one quarter grab bars on 3/16/22 at 7:53 AM. When asked if he used the grab bars, Resident #81 stated, Yes, I use them to help move and get up. An interview was conducted on 3/16/22 at 2:20 PM with LPN (licensed practical nurse) #3, the MDS coordinator. When asked the purpose of the care plan, LPN #3 stated, The purpose is to coordinate the resident care, work out a plan of care for that resident. MDS is responsible for the development of the care plan. When asked if grab bars should be included on the care plan, LPN #3 stated, Yes I believe so. The care plan should be reviewed and revised to include them. When asked why the care plan should include the grab bars, LPN #3 stated, The care plan should include the grab bars because the resident could have injury with the grab bar and we need to review the care plan and check if they still need them. An interview was conducted on 3/16/22 at 3:03 PM with LPN #4. When asked if grab bars should be on the care plan, LPN #4 stated, Yes, they should be on the care plan. Usually under falls. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 6. B. The facility failed to revise the comprehensive care plan to include brace for Resident #81. A review of Resident #81's care plan dated 2/9/22 revealed no information regarding a thoracic lumbar supporting brace. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Can apply himself when sitting on side of bed every shift. The resident was observed wearing his brace on 3/15/22 at 12:55 PM. When asked how often he wears his brace, Resident #81 stated, I put it on in the morning and keep it on till I go to bed. It helps with my back and posture. An interview was conducted on 3/16/22 at 2:20 PM with LPN (licensed practical nurse) #3, the MDS coordinator. When asked the purpose of the care plan, LPN #3 stated, The purpose is to coordinate the resident care, work out a plan of care for that resident. MDS is responsible for the development of the care plan. When asked if a brace should be included on the care plan, LPN #3 stated, Yes, a brace should be on the care plan. An interview was conducted on 3/16/22 at 3:03 PM with LPN #4. When asked if a brace should be on the care plan, LPN #4 stated, Yes, the brace should be on the care plan. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident or RP (responsible party) and ombudsman upon transfer for five of 47 residents in the survey sample were transferred to the hospital; Residents #101, #85, #71, #2 and #74. The findings include: 1. The facility staff failed to evidence written documentation to the Resident or RP and Ombudsman when Resident #101 was transferred to the hospital on 2/19/22. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired Review of Resident #101's nursing progress note dated 2/19/22 at 3:02 PM revealed the following, [Resident #101] Out of bed in wheelchair, noted progressing weakness, unable to sit up straight. Slow respond to verbal and tactile stimuli. Transferred back in bed due to weakness. At lunch writer attempted to feed the resident, unable to open mouth, change in mental status, unable to respond to verbal stimuli .Notified nurse practitioner- send the resident to emergency room (ER) for further evaluation due to change in mental status and unable to respond to verbal stimuli. RP (responsible party) notified and given the change of status update. Resident was sent to the ER via 911 at 2:15 pm and given report to hospital. On 3/15/22 at approximately 5:00 PM, a request was made for the evidence of written documentation to the Resident/RP and Ombudsman when Resident #101 was transferred to the hospital on 2/19/22. On 3/16/22 at 9:32 AM, an interview was conducted with ASM (administrative staff member) #1, the administrator who stated, We have not been sending notification to the ombudsman on hospital transfers. I have talked with the social worker and we will start doing that today, here is the proof of what we sent to the ombudsman this morning. ASM #1 provided copy of email sent to the Ombudsman dated 3/16/22 at 8:16 AM, with Resident #101's name listed. No evidence of written notification to RP was provided. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about ombudsman notification, OSM #5 stated, We are to notify the ombudsman, which is new to me. She stated she was just told this week, and are starting it now. I started at this facility in November. I will do at weekly notification to the ombudsman. I already have a relationship with the ombudsman and he comes in at least once a week. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. According to the facility's Transfer & Discharge Notification policy which reveals, The facility will notify resident, or their representative as well as the Ombudsman of resident transfers and discharge. The facility will notify resident and the representative of transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. No further information was provided prior to exit. 2. The facility staff failed to evidence written documentation to the Resident/RP and Ombudsman when Resident #85 was transferred to the hospital on 2/3/22. Resident #85 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/19/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Review of Resident #85's nursing progress note dated 2/3/22 at 11:23 AM, revealed the following, About 11 AM resident stated that 'I am not doing good. I feel like passing out,' Checked resident's vital signs .Physician notified and new order given to send the resident to nearest ER (emergency room ) for further evaluation and treatment. Resident left with ambulance. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of written documentation to the Resident or RP and Ombudsman when Resident #85 was transferred to the hospital on 2/3/22. On 3/16/22 at 9:32 AM, an interview was conducted with ASM (administrative staff member) #1, the administrator, who stated, We have not been sending notification to the ombudsman on hospital transfers. I have talked with the social worker and we will start doing that today, here is the proof of what we sent to the ombudsman this morning. ASM #1 provided copy of email sent to Ombudsman dated 3/16/22 at 8:16 AM, with Resident #85's name listed. No evidence of written notification to RP was provided. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about ombudsman notification, OSM #5 stated, We are to notify the ombudsman which is new to me. She stated she was just told this week. We are starting it now. I started at this facility in November. I will do at weekly notification to the ombudsman. I already have a relationship with the ombudsman and he comes in at least once a week. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 3. The facility staff failed to evidence written notification of transfer to the resident/RP or notification to the ombudsman for Resident #71's facility-initiated transfer on 1/29/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. The progress notes for Resident #71 documented in part, 1/29/2022 15:16 (3:16 p.m.) Resident observed in bed at beginning of shift with eyes closed and breathing through the mouth. O2 (oxygen) at 2L (two liters)/min (per minute) via nc (nasal cannula). BS (blood sugar) checked. Unable to get reading because BS was high .Resident continued with lip breathing with a lot of [MEDICATION(S)] from mouth. MD (medical doctor) notified. Order: Transfer resident to [Name of hospital] ER (emergency room ) for further eval (evaluation) and treat. R/P (responsible party) notified. Resident pick up at 9:15 am via 911. The clinical record failed to evidence documentation of written notification of transfer to the resident/RP or notification to the ombudsman for the facility-initiated transfer on 1/29/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent bed hold notice and clinical records for facility-initiated transfers but did not send any written notice of transfer to the resident or responsible party. On 3/16/2022 at 9:32 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that they had not been sending notification to the ombudsman for hospital transfers. ASM #1 stated that they had spoken with the social worker and had started doing this that morning. On 3/16/2022 at 10:03 a.m., an interview was conducted with OSM (other staff member) #5, the director of social work. OSM #5 stated that they only spoke with the responsible parties on the phone regarding the bed hold. OSM #5 stated that they had not been notifying the ombudsman of hospital discharges and that they were just told that they were to send them weekly starting now. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 4. The facility staff failed to evidence written notification of transfer to the resident/RP or notification to the ombudsman for Resident #2's facility-initiated transfer on 3/9/2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. The progress notes for Resident #2 documented in part, 3/9/2022 17:50 (5:50 p.m.) Resident was in bed on 2 iitters [sic] of oxygen via nasal canula [sic] at 8:40 am .Circa 9 am CNA (certified nursing assistant) caring for resident informed me that she was unable to eat her breakfast. Upon approaching her bedside, color appeared slightly cyanotic, skin cool to touch, resident was breathing without any difficulty, with oxygen @ 2L (liters) nasal cannula in use . was with definite change in mental status. Unable to respond verbally, no congestion observed. [Name of physician] was in house at the time and informed him of residents change in status. He ordered resident sent out 911. EMS (emergency medical services) was called . The progress notes further documented, 3/9/2022 22:34 (10:34 p.m.) Resident returned from the hospital at 8:45 pm. The clinical record failed to evidence documentation of written notification of transfer to the resident/RP or notification to the ombudsman for the facility-initiated transfer on 3/9/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent bed hold notice and clinical records for facility-initiated transfers but did not send any written notice of transfer to the resident or responsible party. On 3/16/2022 at 9:32 a.m., an interview was conducted with ASM (administrative staff member) #1, the administrator. ASM #1 stated that they had not been sending notification to the ombudsman for hospital transfers. ASM #1 stated that they had spoken with the social worker and had started doing this that morning. On 3/16/2022 at 10:03 a.m., an interview was conducted with OSM (other staff member) #5, the director of social work. OSM #5 stated that they only spoke with the responsible parties on the phone regarding the bed hold. OSM #5 stated that they had not been notifying the ombudsman of hospital discharges and that they were just told that they were to send them weekly starting now. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. 5. The facility staff failed to provide written notification to the resident and/or responsible party for a facility initiated transfer, and failed to notify the ombudsman of a transfer to the hospital for Resident #74. Resident #74 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a significant change Medicare five day assessment, with an ARD (assessment reference date) of 2/11/2022, the resident scored a one on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/31/2022 at 2:42 p.m. documented, Patient alert and restlessness with tachypnea and [CONDITION(S)] .Patient stated, 'I am not feeding (sic) good,' moving all-around in bed, very irritable. MD (medical doctor) notified, new order given to give nebulizer treatment was given one time. Patient still noticed restlessness and fast breathing. Called 911 and sent to ER (emergency room ) for further evaluation and treatment. MD made aware and responsible party, son [name of son] notified. Report is given to [Name of hospital] ER nurse. All paper work with med (medications) were given to 911 staff. Review of the clinical record on 3/16/2022 failed to evidence a written notification for the reason for the transfer to the hospital on 1/31/2022 for Resident #74 was provided to the resident and/or responsible party. And further investigation revealed there was no notification of the ombudsman of the transfer of Resident #74 to the hospital on 1/31/2022. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 3/16/2022 at 9:32 a.m. ASM #1 stated, We have not been sending notification to the ombudsman on hospital transfers. I've talked with the social worker and will start doing that today. Here is the proof of what we sent to the ombudsman this morning. An interview was conducted with OSM (other staff member) #5, the director of social services on 3/16/2022 at 10:03 a.m. When asked about notifying the ombudsman of a resident's transfer to the hospital, OSM #5 stated Notifying the ombudsman is new to me. I was just told this week about it and am starting it now. I will do it weekly, I already have a relationship with the ombudsman and he comes in at least once a week. Multiple requests were made for the documentation of the written notification to the resident and/or responsible party upon transfer to the hospital. Nothing was provided prior to exit. ASM #1, ASM #2, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility, and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 47 residents in the survey sample were transferred to the hospital; Residents #101, #85, #71, #2 and #74. The findings include: Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence that all required information was provided to the hospital staff when five of 47 residents in the survey sample were transferred to the hospital, Residents #101, #85, #71, #2 and #74. The findings include: 1. The facility staff failed to provide evidence that care plan goals were provided to the hospital staff when Resident #101 was transferred to the hospital on 2/19/22. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Review of Resident #101's nursing progress note dated 2/19/22 at 3:02 PM revealed the following, [Resident #101] Out of bed in wheelchair, noted progressing weakness, unable to sit up straight. Slow respond to verbal and tactile stimuli. Transferred back in bed due to weakness. At lunch writer attempted to feed the resident, unable to open mouth, change in mental status, unable to respond to verbal stimuli .Notified nurse practitioner- send the resident to emergency room (ER) for further evaluation due to change in mental status and unable to respond to verbal stimuli. RP (responsible party) notified and given the change of status update. Resident was sent to the ER via 911 at 2:15 pm and given report to hospital. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of information provided to the receiving facility when Resident #101 was transferred to the hospital. On 3/16/22 at 12:16 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator and ASM #2 the director of nursing. ASM #1 provided a blank envelope compliance checklist: transfer/discharge requirements, which lists required documents. ASM #1 then stated, We recognized that the nurses are not making copies of the envelope of what is sent to the hospital for the residents going to the hospital. We have started whole house staff education for our nurses and going forward we will be making copies of this checklist and placing in the resident's record. ASM #2 then stated, We need to make sure the nurses are complying. From this point forward we will be checking on this. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. According to the facility's Transfer or Discharge Requirements policy: Facility staff will ensure the following is provided when a resident is transferring or discharging from the facility. This is important for ensuring a safe and appropriate discharge which promotes continuity of care. List includes: face sheet, physician orders, diagnosis/allergies, advance directives, care plan goals, recent labs, isolation information, recent medications, recent nurse's notes, resident status, special instructions and copy of bed hold notice. No further information was provided prior to exit. 2. The facility staff failed to provide evidence that care plan goals were provided to the hospital staff when Resident #85 was transferred to the hospital on 2/3/22. Resident #85 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/19/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Review of Resident #85's nursing progress note dated 2/3/22 at 11:23 AM, revealed the following, About 11 AM resident stated that 'I am not doing good. I feel like passing out,' Checked resident's vital signs .Physician notified and new order given to send the resident to nearest ER (emergency room ) for further evaluation and treatment. Resident left with ambulance. On 3/15/22 at approximately 5:00 PM a request was made for evidence of information provided to the receiving facility when Resident #85 was transferred to the hospital on 2/3/22. On 3/16/22 at 12:16 PM, an interview was conducted with ASM (administrative staff member) #1, the administrator and ASM #2 the director of nursing. ASM #1 provided a blank envelope compliance checklist: transfer/discharge requirements which lists required documents. ASM #1 then stated, We recognized that the nurses are not making copies of the envelope of what is sent to the hospital for the residents going to the hospital. We have started whole house staff education for our nurses and going forward we will be making copies of this checklist and placing in the resident's record. ASM #2 then stated, We need to make sure the nurses are complying. From this point forward we will be checking on this. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 3. The facility staff failed to evidence care plan goals were provided for Resident #71 to the receiving provider for a facility-initiated transfer on 1/29/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. The progress notes for Resident #71 documented in part, 1/29/2022 15:16 (3:16 p.m.) Resident observed in bed at beginning of shift with eyes closed and breathing through the mouth. O2 (oxygen) at 2L (two liters)/min (per minute) via nc (nasal cannula). BS (blood sugar) checked. Unable to get reading because BS was high .Resident continued with lip breathing with a lot of [MEDICATION(S)] from mouth. MD (medical doctor) notified. Order: Transfer resident to [Name of hospital] ER (emergency room ) for further eval (evaluation) and treat. R/P (responsible party) notified. Resident pick up at 9:15 am via 911. The clinical record failed to evidence documentation of information provided to the hospital on 1/29/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent an envelope containing documents with residents to the hospital when the resident is transferred out. LPN #5 stated that the envelope had a checklist on it that they followed. LPN #5 stated that they sent a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs in the envelope and called a report to the hospital. LPN #5 stated that they should document what was sent in the progress notes because they do not copy the envelope that was sent. LPN #5 stated that some of the nurses were good about making the notes and some were not. On 3/16/2022 at 12:16 p.m., ASM (administrative staff member) #1, the administrator stated that they did not have evidence of transfer documents sent to the hospital and that the nurses were not making copies of the envelope sent with the resident to the hospital containing the documents. ASM #1 stated that that going forward they planned to make copies of the envelopes. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 4. The facility staff failed to evidence care plan goals were provided for Resident #2 to the receiving provider for a facility-initiated transfer on 3/9/2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/23/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact. The progress notes for Resident #2 documented in part, 3/9/2022 17:50 (5:50 p.m.) Resident was in bed on 2 iitters [sic] of oxygen via nasal canula [sic] at 8:40 am .Circa 9 am CNA (certified nursing assistant) caring for resident informed me that she was unable to eat her breakfast. Upon approaching her bedside, color appeared slightly cyanotic, skin cool to touch, resident was breathing without any difficulty, with oxygen @ 2L (liters) nasal cannula in use . was with definite change in mental status. Unable to respond verbally, no congestion observed. [Name of physician] was in house at the time and informed him of residents change in status. He ordered resident sent out 911. EMS (emergency medical services) was called . The progress notes further documented, 3/9/2022 22:34 (10:34 p.m.) Resident returned from the hospital at 8:45 pm. The clinical record failed to evidence documentation of information provided to the hospital on 3/9/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent an envelope containing documents with residents to the hospital when transferred out. LPN #5 stated that the envelope had a checklist on it that they followed. LPN #5 stated that they sent a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs in the envelope and called a report to the hospital. LPN #5 stated that they should document what was sent in the progress notes because they do not copy the envelope that was sent. LPN #5 stated that some of the nurses were good about making the notes and some were not. On 3/16/2022 at 12:16 p.m., ASM (administrative staff member) #1, the administrator stated that they did not have evidence of transfer documents sent to the hospital and that the nurses were not making copies of the envelope sent with the resident to the hospital containing the documents. ASM #1 stated that that going forward they planned to make copies of the envelopes. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 5. The facility staff failed to evidence care plan goals were provided to the receiving facility for a facility initiated transfer for Resident #74 on 1/31/2022. Resident #74 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a significant change Medicare five day assessment, with an ARD (assessment reference date) of 2/11/2022, the resident scored a one on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/31/2022 at 2:42 p.m. documented, Patient alert and restlessness with tachypnea and [CONDITION(S)] .Patient stated, 'I am not feeding (sic) good,' moving all-around in bed, very irritable. MD (medical doctor) notified, new order given to give nebulizer treatment was given one time. Patient still noticed restlessness and fast breathing. Called 911 and sent to ER (emergency room ) for further evaluation and treatment. MD made aware and responsible party, son [name of son] notified. Report is given to [Name of hospital] ER nurse. All paper work with med (medications) were given to 911 staff. Review of the clinical record on 3/15/2022 failed evidence documentation that the care plan goals were sent with the Resident # 74 upon transfer to the hospital on 1/31/2022. An interview was conducted with LPN (licensed practical nurse) #5 on 3/16/2022 at 12:08 p.m. When asked the process for sending a resident to the hospital, LPN #6 stated, When we transfer a resident to the hospital we send an envelope with them, the envelope has a checklist on it. We send a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs and we call a report to the hospital. We also send a bed hold notice with them. When asked where this should be documented, LPN #5 stated, We should document this in the progress note, we do not make a copy of anything. Some of the nurses are good about making the notes and some are not. On 3/16/2022 at 12:16 p.m. ASM (administrative staff member) #1, the administrator, stated, We recognized that the nurses are not making copies of the envelope of what is sent to the hospital for the residents going to the hospital. We have started a whole hospital education for our nurses and going forward will be making copies of this. ASM #2, the director of nursing, stated, We need to make sure the nurses are complying from this point forward. We will be checking on this. ASM #1, ASM #2, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility, and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide a notice of bed hold when the resident was transferred to the hospital for four of 47 residents in the survey sample, Residents #101, #85, #71 and #74. The findings include: 1. The facility staff failed to evidence a bed hold was provided when Resident #101 was transferred to the hospital on 2/19/22. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #101's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 7 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired Review of Resident #101's nursing progress note dated 2/19/22 at 3:02 PM revealed the following, [Resident #101] Out of bed in wheelchair, noted progressing weakness, unable to sit up straight. Slow respond to verbal and tactile stimuli. Transferred back in bed due to weakness. At lunch writer attempted to feed the resident, unable to open mouth, change in mental status, unable to respond to verbal stimuli .Notified nurse practitioner- send the resident to emergency room (ER) for further evaluation due to change in mental status and unable to respond to verbal stimuli. RP (responsible party) notified and given the change of status update. Resident was sent to the ER via 911 at 2:15 pm and given report to hospital. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of a bed hold notification when Resident #101 was transferred to the hospital on 2/19/22. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about the bed hold notification being provided, OSM #5 stated, I talk with the family about a bed hold and talk with admitting about it. I communicate with the family. I do not know if anything is documented. An interview was conducted on 3/16/22 at 3:30 PM with OSM #8, the admissions director. When asked if a bed hold notification is provided to residents who are transferred to the hospital, OSM #8 stated, There is no evidence of documentation of bed hold offered to these residents. We do not give them a copy of the bed hold form. We verbally discussed with the RP. Not sure if it has been documented. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. According to the facility's Bed Hold Notice Upon Transfer policy: At the time of transfer for the hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. No further information was provided prior to exit. 2. The facility staff failed to evidence a bed hold was provided when Resident #85 was transferred to the hospital on 2/3/22. Resident #85 was admitted to the facility on [DATE]. Resident #85's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/19/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Review of Resident #85's nursing progress note dated 2/3/22 at 11:23 AM, revealed the following, About 11 AM resident stated that 'I am not doing good. I feel like passing out,' Checked resident's vital signs .Physician notified and new order given to send the resident to nearest ER (emergency room ) for further evaluation and treatment. Resident left with ambulance. On 3/15/22 at approximately 5:00 PM a request was made for the evidence of a bed hold notification when Resident #101 was transferred to the hospital on 2/19/22. An interview was conducted on 3/16/22 at 10:03 AM with OSM (other staff member) #5, the director of social services. When asked about the bed hold being provided, OSM #5 stated, I talk with the family about a bed hold and talk with admitting about it. I communicate with the family. I do not know if anything is documented. An interview was conducted on 3/16/22 at 3:30 PM with OSM #8, the admissions director. When asked if a bed hold is provided to residents transferred to the hospital, OSM #8 stated, There is no evidence of documentation of bed hold offered to these residents. We do not give them a copy of the bed hold form. We verbally discussed with the RP. Not sure if it has been documented. On 3/16/22 at 5:25 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, the administrator at sister facility and RN #3, staff development coordinator were informed of the above concern. No further information was provided prior to exit. 3. The facility staff failed to provide bed hold notice for Resident #71's facility-initiated transfer on 1/29/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. The progress notes for Resident #71 documented in part, 1/29/2022 15:16 (3:16 p.m.) Resident observed in bed at beginning of shift with eyes closed and breathing through the mouth. O2 (oxygen) at 2L (two liters)/min (per minute) via nc (nasal cannula). BS (blood sugar) checked. Unable to get reading because BS was high .Resident continued with lip breathing with a lot of [MEDICATION(S)] from mouth. MD (medical doctor) notified. Order: Transfer resident to [Name of hospital] ER (emergency room ) for further eval (evaluation) and treat. R/P (responsible party) notified. Resident pick up at 9:15 am via 911. The clinical record failed to evidence documentation of bed hold notice provided for the facility-initiated transfer on 1/29/2022. On 3/16/2022 at 12:08 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that they sent an envelope with documents with residents to the hospital with them when transferred out. LPN #5 stated that the envelope had a checklist on it that they followed. LPN #5 stated that the documents they sent to the hospital included a bed hold notice. LPN #5 stated that they should document what was sent in the progress notes because they do not copy the envelope that was sent. LPN #5 stated that some of the nurses were good about making the notes and some were not. On 3/16/2022 at 10:03 a.m., an interview was conducted with OSM (other staff member) #5, the director of social work. OSM #5 stated that they only spoke with the responsible parties on the phone regarding the bed hold. On 3/16/2022 at 3:30 p.m., an interview was conducted with OSM (other staff member) #8, the admissions director. OSM #8 stated that they did not have evidence of a bed hold provided to Resident #71. OSM #8 stated that they do not give a copy of the bed hold form, that they verbally discuss the bed hold with the responsible party and was unsure if it was documented. On 3/16/2022 at 5:20 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, administrator of a sister facility and RN (registered nurse) #3, staff development were notified of the findings. No further information was provided prior to exit. 4. The facility staff failed to provide a written copy of the bed hold policy upon transfer to the hospital on 1/31/2022 for Resident #74. Resident #74 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set) assessment, a significant change Medicare five day assessment, with an ARD (assessment reference date) of 2/11/2022, the resident scored a one on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The nurse's note dated 1/31/2022 at 2:42 p.m. documented, Patient alert and restlessness with tachypnea and [CONDITION(S)] .Patient stated, 'I am not feeding (sic) good,' moving all-around in bed, very irritable. MD (medical doctor) notified, new order given to give nebulizer treatment was given one time. Patient still noticed restlessness and fast breathing. Called 911 and sent to ER (emergency room ) for further evaluation and treatment. MD made aware and responsible party, son [name of son] notified. Report is given to [Name of hospital] ER nurse. All paper work with med (medications) were given to 911 staff. An interview was conducted with LPN (licensed practical nurse) #5 on 3/16/2022 at 12:08 p.m. When asked the process for sending a resident to the hospital, LPN #6 stated, When we transfer a resident to the hospital we send an envelope with them, the envelope has a checklist on it. We send a face sheet, the history and physical, the progress notes, the care plan, the change in condition form, and labs and we call a report to the hospital. We also send a bed hold notice with them. When asked where this should be documented, LPN #5 stated, We should document this in the progress note, we do not make a copy of anything. Some of the nurses are good about making the notes and some are not. A request was made for the documentation of the bed hold provided to Resident #74 and/or her responsible party on 3/15/2022 at 5:00 p.m. On 03/16/2022 at 3:31 p.m., OSM #8, the director of admissions stated, From what I understand, the family did not formally pay for a bed hold. OSM #8 stated she would further investigate this. On 3/16/2022 at 3:36 p.m. OSM #8 stated, We do not give them a copy of the bed hold form, it's verbally discussed with the RP (responsible party). When asked where the verbal discussion is documented, OSM #8 stated for [Resident #74], it is not documented. ASM #1, ASM #2, ASM #3, the assistant director of nursing, ASM #4, administrator from a sister facility, and RN (registered nurse) #3, the staff development nurse, were made aware of the above concern on 3/16/2022 at 5:30 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program by implementing non-pharmacological interventions prior to the administration of a prn (as needed) pain medications for one of 47 residents in the survey sample, Residents # 56. The findings include: The facility staff failed to implement non-pharmacological interventions prior to the administration of [MEDICATION(S)]-acetaminophen (1) to Resident #56. Resident # 56 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/27/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J coded Resident # 56 as not having any pain in the past 5 (five) days. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth twice daily as needed. Order Date: 04/23/2021. Resident #56's eMAR (electronic medication administration record) for March 2022 documented the administration of the [MEDICATION(S)]-Acetaminophen as documented above on the following dates and times, with no evidence of non-pharmacological interventions being attempted: 03/01/2022 at 4:31 p.m., 03/02/2022 at 7:23 a.m., 03/03/2022 at 4:54 p.m., 03/04/2022 at 5:42 p.m., 03/07/2022 at 7:00 p.m., 03/09/2022 at 9:19 p.m., 03/13/2022 at 5:22 a.m. and on 03/15/2022 at 4:44 p.m. The comprehensive care plan for Resident # 56 dated 04/29/2021 failed to evidence information related to pain. On 03/17/22 at approximately 10:52 a.m., an interview was conducted with Resident # 56. When asked if they receive pain medication as needed Resident # 56 stated, Sometimes. When asked if the staff try to alleviate their pain before giving them pain medication Resident # 56 stated Sometimes. On 03/16/2022 at approximately 1:55 p.m. an interview was conducted with LPN (licensed practical nurse) # 2 regarding the procedure for administering prn (as needed) pain medication and documentation of non-pharmacological interventions. LPN # 2 stated, Assess the resident's pain, where the pain is and using a scale one to ten, with ten being the worse pain. Attempt interventions, like repositioning, to alleviate their pain, if it doesn't work administer the pain medication and recheck the resident for effectiveness. When asked how often the non-pharmacological interventions should be attempted LPN # 2 stated, Before you give the medication, every time. When asked about where the non-pharmacological interventions should be documented, LPN # 2 stated, It's documented in the nurse's notes. After reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 56 receiving the physician ordered pain medication of [MEDICATION(S)] on the dates listed above. LPN # 2 stated, No. The facility's policy Policy on Pain Management documented in part, POLICY STATEMENT: It is the policy of the facility to ensure that our residents are comfortable and free of pain as possible. Pain Management: Provide non pharmacological approach as needed or as requested by the resident. On 03/16/2022 at approximately 5:00 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, assistant director of nursing, ASM # 4, administrator from sister facility and RN # 4, staff development, were made aware of the findings. No further information was provided prior to exit. References: (1) Indicated for the management of pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate. This information was obtained from the website: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f2137f1a-b49a-40bd-97ac-cd6b36e295f4.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed for 1 resident (Resident #10) of the survey sample of 28 residents, to identify a pressure ulcer on the left heel prior to it developing to Stage 3, resulting in harm. For Resident #10, the facility staff failed to identify a pressure ulcer prior to it developing to Stage 3. Definitions of pressure ulcers provided by NPUAP (National Pressure Ulcer Advisory Panel): Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput (back of head), and malleolus (ankle bone) do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity (fatty tissue) can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. The Findings included: Resident #10 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #10's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment, had an Assessment Reference Date of 6/22/16. Resident #10 was coded as having a Brief Interview of Mental Status Score of 3, indicating severely impaired cognition. In addition, she was coded as having range of motion limits in both her upper and lower extremities. She was coded as requiring the extensive assistance of 2 people for transfers. On 7/13/16, at 9:00 A.M. a review was conducted of Resident #10's clinical record, revealing a Wound Assessment Report. It read, Date wound identified - 7/6/16, Location: Left Heel, Assessment Occasion: New Wound, Stage 3, Drainage: Serous/Small, Measurements: Length - 0.90 cm (centimeters), Width: 1.2 cm, Depth: 13.00 cm. Surrounding skin: Macerated. The wound bed was not described. The wound edges were not described. The Director of Nursing was interviewed on 7/13/16 at 10:00 A.M. She stated that there was a typo on the report, and that the correct Depth was 3.00 cm., not 13 cm. She also stated that the wound report was dated incorrectly. The wound was first identified on 6/30/16, not 7/6/16, which was verified by the wound nurse (Licensed Practical Nurse A, who wrote the report). Resident #10's Physician order [REDACTED]. Clean left heel with wound cleanser pat dry apply Silversorb gel (SilverSorb is manufactured by Medline. According to www.medline.com <http://www.medline.com>, indication for use was as follows: For lightly draining wounds in need of antimicrobial barrier. Helps manage bacterial burden. Indications: Pressure Injuries. 2) 7/2/16. Apply Zinc Oxide to sacrum (buttocks) three times daily and as needed for moisture reduction. The National Institutes of Health ' s U.S. Library of Medicine describes zinc oxide as follows: Zinc Oxide is a mild astringent and topical protectant with some antiseptic action. Their website is: <https://pubchem.ncbi.nlm.nih.gov/compound/ > On 7/13/16 at 2:30 P.M. an interview was conducted with Licensed Practical Nurse (LPN) A. He stated that he identified the pressure ulcer on Resident #10's left heel, but didn't describe the wound bed because he didn't want to describe it, in case his description would be different from the wound care physician's description. He also stated that the wound on the sacrum was an old wound that had re-opened. He was unable to state any interventions that had been put in place to prevent the wound from re-opening. The clinical record also contained 2 Wound Care Specialist Evaluations. 1) 7/6/16. Stage 3 pressure would of the left heel greater than 1 days duration. Wound size L x W x D: 0.9 x 1.2 x 0.3 cm. 100% Granulation tissue. (According to Authors Potter and Perry, Fundamentals of Nursing 7th ed. page 1282, granulation tissue is red moist tissue composed of new blood vessels, the presence of which indicated progression towards healing. Soft yellow of white tissue is characteristic of slough - stringy substance attached to wound bed.) Dressing: Silver Hydrogel every 3 days, Foam every 3 days. 2) 7/13/16. Stage 3 pressure ulcer Left Heel. Wound size: Lx W x D = 0.5 x 0.9 x 0.3 cm. 100% granulation tissue. ( Duration greater than 7 days. Dressing: Silver Hydrogel every 3 days, Foam every 3 days. Recommendation: Off -Load wound, Reposition per facility protocol. This report also stated that Resident #10 had a Stage 2 pressure wound on her sacrum of greater that 1 days duration. This sacral wound had 100% granulation tissue. According to a Wound Assessment Report dated 7/6/16, the sacrum wound was a reopened wound that was found at stage 2. A Nurse's note dated 6/30/16 read, Resident was noted with old scar reopen to right buttocks, barrier cream apply to site. Call place to RP (Responsible Party) for update message. The NPUAP (National Pressure Advisory Panel) definitions of a Stage II pressure ulcer: Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration, or excoriation. *Bruising indicates suspected deep tissue injury. The clinical record also contained a Braden Risk Assessment Report dated 5/21/15, and 6/24/16. Both reports identified Resident #10 as having a High Risk Level for the development of pressure ulcers. Although Resident #10 had been previously identified as being at high risk for pressure wound development, her care plan did not address her history of pressure wounds, to prevent re-opening. Three observations were made of Resident #10 during the survey. She was always lying in the same position, which was on her back. According to her Resident Turning Schedule, on 7/12/16 at 4:00 P.M. she was on her back, when she should have been turned toward the window. On 7/12/13 at 4:45 P.M., she was still lying on her back when the surveyor conducted an observation of her wound. On 7/13/16 at 10:00 A.M. she was lying on her back, instead of facing the window. The surveyor observed a Stage 3 wound on Resident #10's heel with 30% maceration, slough and minimal drainage. Another surveyor observed a Stage 2 pressure wound on Resident #10's sacrum, with 20% granulation and slough. Resident #10's Bath Roster was reviewed. Bed baths were given on 6/29/16, 7/2/16, and 7/6/16. There was no documentation that any skin abnormalities were reported. On 7/13/16 at 11:00 A.M. a review of facility documentation was conducted, revealing a Wound Care Management Policy revised on 3/13/15. It read, Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible. Each resident is evaluated by the interdisciplinary team to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation is conducted by the interdisciplinary team to ensure appropriate measures are in place to minimize further compromise and aid in healing to the extent possible. On 7/13/16 at 11:28 A.M. an interview was conducted with the DON (Director of Nursing) in the conference room. She stated that the care plans are updated quarterly, and as needed. She also said that the nursing staff are responsible for updating any nursing related issues on the care plan. When asked of it was appropriate to wait a week or more before updating a care plan, she stated, No. When asked about how bed baths are given by Certified Nursing Assistants, the DON stated, They clean from head to toe. They use several washcloths. They clean the feet. They call the nurse if there are any skin abnormalities. The DON was also asked about the importance of describing the wound bed during an initial assessment of a pressure wound. She stated, It is important to describe the wound bed in order to know what stage it is and what treatment should be done. On 7/13/16 at 8:30 A.M. an interview was conducted with the Wound Care Physician, (Other A). When asked about the importance of identifying a pressure wound prior to it becoming Stage 3, he stated, You know the answer. You'd like to catch it in as early a stage as possible. On 7/13/16 at 4:30 P.M. the facility Administrator (Administration A) was informed of the findings. No further information was received. This is a harm level deficiency.

Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to safely store two E cylinders of oxygen for two Residents (Resident #10 and #11) in a survey sample of 26 Residents resulting in immediate jeopardy and substandard quality of care. After removal of the immediate jeopardy, the scope and severity was lowered to a level 2, isolated. Two E cylinders of oxygen were stored unsecured on a ledge approximately 3 feet from the end of Resident #10's bed. The findings included: Resident #10, a female, was initially admitted to the facility 10/8/09 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set) with an ARD (assessment reference date) of 7/16/13 was coded as a quarterly assessment. Resident #10 was coded as having short and long term memory deficits and required moderate assistance in making daily life decisions. She was coded as requiring extensive two person assistance for her activities of daily living. Resident #11, a female, was admitted to the facility 8/15/13. Her [DIAGNOSES REDACTED]. Resident #11's most recent MDS (minimum data set) with an ARD (assessment reference date) of 8/22/13 was coded as an admission, five day assessment. Resident #11 was coded as having short term memory deficits and was able to make her own daily life decisions. She was coded as requiring extensive assistance of one staff member to perform her activities of daily living. Resident #11 was coded as having a fall in the last 6 months with a fracture. The team entered the facility for a standard and complaint, licensure survey at 2:15 p.m. on 9/24/13. The tour began on the 100's hall with RN (registered nurse) B, the unit manager. After meeting and observing the Residents in the first 3 rooms, Resident #10 and #11's bedroom was approached. After knocking, the room was entered at approximately 2:30 p.m. Two Residents were in the room, with Resident #10 being in the bed next to the window and Resident #11 in her bed next to the door. Resident #10 was observed lying in bed, with the head of the bed elevated. Pillows were observed for positioning. Resident #10 was receiving oxygen at 2 liter per minute via nasal cannula. A nasal cannula is a tubing that delivers oxygen directly into the nostrils. The oxygen was being generated by a oxygen concentrator, sitting on the floor next to her bed. After talking with Resident #10, her part of the bedroom was observed. Sitting on a ledge (approximately 5-6 inches from the floor) at the wall by the windows, two E cylinders of oxygen were observed. Neither cylinder was secured to any safety devices. Another cylinder was secured in a moveable wheeled device, sitting on the floor adjacent to the two unsecured cylinders on the ledge. Caps were covering the top of the oxygen cylinders indicating the oxygen cylinders were full and had not been accessed for use. Resident #11 was observed laying on her bed with her eyes closed. Resident #11 was soft spoken and only spoke with encouragement. A personal alarm was noted, clipped to her blouse. RN (Registered Nurse) B entered the room and waited in the room while Resident #10 and #11 were speaking. RN B exited the room and assisted with the rest of tour. RN B did not mention the unsecured E cylinders, however she did note that Resident #10 was receiving hospice services and utilized oxygen all of the time. The tour was concluded on the rest of the unit with no other unsecured oxygen cylinders observed in any of the other Resident's bedrooms. Upon returning to the conference room at 3:25 p.m., the team was informed of the observation of unsecured oxygen cylinders on the ledge in Residents' #10 and #11 bedroom. A second surveyor entered Residents #10 and #11's bedroom and observed two unsecured cylinders of oxygen on the ledge under the windows at 3:30 p.m. Resident bedrooms were rechecked with no other observations of unsecured oxygen E cylinders. After reviewing the guidelines for immediate jeopardy, the team determined that immediate jeopardy was in place for Resident #10 and #11 due to unsecured oxygen e cylinders stored on the ledge in their bedroom. The supervisor at the State Agency (SA) was contacted at 3:55 p.m. and the immediate jeopardy observations were discussed. Further information was requested by the SA regarding manufacturer's instructions and the facility's policy regarding oxygen storage. When interviewed, Other J, the central supply coordinator, stated 9/24/13 at 4:10 p.m., oxygen was stored in the basement. Other J stated she was unaware of any manufacturers instructions or facility policy regarding the storage of oxygen tanks or cylinders. The DON (director of nursing) provided the facility's policy for "OXYGEN SAFETY" that included: "1. Oxygen cylinders must be stored in racks with chains, sturdy portable carts and/or approved stands. 7. Oxygen cylinders my not be stored in any resident's room or living area. 9. Oxygen cylinders may not be left free standing. They must be securely fastened at all times." The SA was contacted and informed of the above information at 4:32 p.m. The SA agreed and Immediate Jeopardy was called at 4:35 p.m. The administrator and DON were informed of the presence of Immediate Jeopardy for Residents' #10 and #11 at 4:42 p.m. At 4:45 p.m. the administrator and DON (Director of Nursing) exited the conference room to develop a plan of action to abate the Immediate Jeopardy (IJ). At 5:22 p.m., the administrator and DON presented a plan to remove the IJ. Resident #10 and #11's bedroom was observed 5:35 p.m. and the unsecured oxygen cylinders had been removed. The initial plan of removal was rejected as the training plan and AOC (allegation of compliance date) were unclear. The administrator and DON left the conference room and returned at 5:43 p.m. with another plan. The plan was accepted with the IJ removed at 5:43 p.m. At 5:57 p.m., the SA was informed of the acceptance of the plan and removal of IJ. The plan included: "1. Oxygen cylinders were removed from room (Resident #10 & #11) and brought to storage room. No ill effects were observed for either resident. Completion date 9/24/13 at 4:48 p.m. 2. Audit of all resident rooms and common areas for Oxygen cylinders not currently in use. Remove cylinders not actively in use and transfer to oxygen storage room. Secure cylinders appropriately. Completion date 9/24/13 3. Educate all staff regarding proper storage of oxygen cylinders. Educate all staff on proper oxygen storage policies and handling before any employee is to work their next scheduled shift. Completion date 9/24/13 and ongoing thereafter. 4. Educate all Hospice vendors and oxygen vendor regarding proper delivery instructions and handling requirements for oxygen cylinders for (facility name). Completion date 9/24/13 5. Conduct audit of all resident rooms q (every) shift for oxygen cylinders x (times) 7 days, then daily thereafter. Results of rounds to be presented to DON or Administrator, and reviewed with Quality Assurance Committee monthly. Any needed corrections to be implemented at that time. Completed 9/24/13 and ongoing." The DON stated 9/25/13 at 10:10 a.m., the oxygen cylinders had been provided by a hospice vendor. The DON was unable to verbalize how long the oxygen cylinders had been stored unsecured in Resident #10 and #11's bedroom. When interviewed, RN (Registered Nurse) B stated 9/25/13 at 10:30 a.m., she remembered seeing the oxygen cylinders during tour, however she did not recall they were unsecured. Other F, the hospice nurse case manager, said 9/25/13 at 11:10 a.m., the oxygen cylinders had been provided by a vendor that contracted with the hospice provider. Other F was unable to state how long the oxygen cylinders had been stored in the bedroom. Other G, an office manager of the vendor, stated 9/25/13 at 11:45 a.m., two oxygen cylinders and a rolling secure cart had been delivered to Resident #10's bedroom [ROOM NUMBER]/12/13 at 3 p.m. Other G stated the delivery staff were responsible for ensuring the oxygen was left in a secure cart prior to leaving the facility. Other G stated their practice was for the delivery staff to inform the Resident and any available staff of the care and storage of oxygen when it was delivered. Guidance was provided at www.[MEDICATION NAME].com with interpretation of the guidelines for Life Safety: "Oxygen cylinders store [MEDICATION NAME] oxygen under a very high pressure (2,000 psi-pounds per square inch). Oxygen cylinders must be stored in a rack or stand and empty cylinders must be stored away from full cylinders" Additionally, guidance was provided by Joint Commission at www.jointcommission. org, "It may be impractical for some organizations to have piped nonflammable medical gases, so they may provide these gases in freestanding cylinders of various sizes. All freestanding cylinders must be stored in a rack, a cart, or another enclosure to protect them. Unsecured cylinders could fall, breaking the valve and possibly resulting in a rapid release of the gas, propelling the cylinder and turning it into a dangerous projectile." On 9/26/13 at 12:10 P.M. the administrator, DON, and corporate consultants were advised of the failure of the staff to ensure oxygen cylinders were stored in a secure manner for Residents' #10 and #11 resulting in Immediate Jeopardy.